Nursing Process Practice Questions

Correct Answer: D

Rationale: The correct answer is D: Pallor, tachycardia, and a sore tongue. Pernicious anemia is caused by a deficiency in vitamin B12, leading to symptoms such as pallor (due to decreased red blood cells), tachycardia (as the heart works harder to compensate for decreased oxygen-carrying capacity of the blood), and a sore tongue (due to inflammation of the tongue). Choice A is incorrect because bradycardia would not be expected in pernicious anemia, and reduced pulse is not a typical finding. Choice B is incorrect because weight gain is not a common symptom of pernicious anemia. Choice C is incorrect because angina and double vision are not typical findings of pernicious anemia, and anorexia is more likely due to other causes.

Correct Answer: A

Rationale: Correct Answer: A - Cerebral edema Rationale: 1. SIADH leads to water retention and dilutional hyponatremia. 2. Diuretic therapy aims to increase urine output and correct fluid imbalance. 3. If the client does not comply, excessive water retention can lead to cerebral edema. 4. Cerebral edema is a serious complication that can cause neurological deficits. Summary: - B: Severe hyperkalemia is unlikely as diuretics would help excrete excess potassium. - C: Hypovolemic shock is not expected as fluid restriction may prevent rapid volume loss. - D: Tetany is not a direct consequence of non-compliance with treatment for SIADH.

Correct Answer: C

Rationale: Rationale: 1. Abdominal injection sites have a higher blood supply, leading to faster absorption. 2. Insulin absorption is faster in areas with more blood vessels. 3. Rapid absorption at the abdomen results in quicker onset of action. 4. Other sites may have slower absorption due to less blood flow. Summary: A: Incorrect. Absorption is faster at abdominal sites due to increased blood flow. B: Incorrect. Absorption varies based on injection site blood supply. C: Correct. Abdominal injection sites have rapid insulin absorption. D: Incorrect. Insulin absorption is consistent based on blood flow at injection sites.

Correct Answer: D

Rationale: The correct answer is D because developing a formal nursing diagnosis helps nurses focus on their scope of practice, which includes identifying and addressing the patient's nursing care needs. By formulating a clear nursing diagnosis, nurses can prioritize interventions that are within their domain of expertise. This ensures efficient and effective patient care delivery. A: Incorrect. Developing a nursing diagnosis is not about creating a language exclusive to nurses; it is about identifying patient care needs. B: Incorrect. While nursing diagnoses do delineate the nurse's role, the primary purpose is not to distinguish it from the physician's role. C: Incorrect. Nursing diagnoses are based on evidence and critical thinking, not solely on intuition or others' judgments.

Correct Answer: B

Rationale: The correct answer is B because providing frequent mouth care to Mr. Franco helps in removing dried blood when his tongue is bitten during a seizure, preventing infection and promoting oral hygiene. This is crucial in preventing complications and ensuring Mr. Franco's overall well-being. Choice A is incorrect because thirst is not directly related to mouth care, and increasing fluids intake would address dehydration more effectively. Choice C is incorrect as tactile stimulation may not necessarily hasten return to consciousness in this context. Choice D is incorrect as it refers to a different issue related to mouth breathing in comatose patients, which is not the immediate concern addressed by frequent mouth care in this scenario.